Working Together for a Healthier Scotland

Chapter 2 - Scotland's Health

Major Health Problems

6. Tackling Scotland’s health problems is not just about confronting major diseases and illness. It is also about recognising and attacking the health inequalities which have increasingly seen the more affluent enjoy much better health than people who are less well off.

Coronary Heart Disease, Cancer and Stroke

7. The two most common causes of death in Scotland are coronary heart disease (CHD) and cancer, each of which accounted for approximately a quarter of all deaths in 1996. In the same year, among people aged under 65, cancer was responsible for almost one third of deaths, and CHD for just under a fifth. Stroke is the third largest killer, and the three diseases are increasingly referred to as ‘Scotland’s Big 3’ in attempting to place them firmly on the public agenda. It is no surprise that cardiovascular disease (including CHD and stroke) and cancer have been identified as major priorities for the NHS in Scotland.

Table 1: Causes of Death in Scotland, 1996

8. Targets for reducing premature deaths from CHD and cancer were set in Scotland’s Health: A Challenge to Us All. That for CHD is a 40% reduction in mortality between 1990 and 2000 among those under 65; and, for cancer, a 15% reduction between 1986 and 2000. Significant progress has been made towards these targets. Over the last decade the mortality rate from CHD has fallen by 40%, and if this trend is maintained, the target set for the year 2000 should be met (Figure 1).

Figure 1

9. The progress in reducing premature deaths from cancer has been more modest, but again the target set for the year 2000 should be achieved if recent trends continue (Figure 2).

Figure 2

10. Despite the improvements that have taken place since the mid-1980s, Scotland’s health record remains poor. The £1.25 billion in 1996-97 for incapacity and invalidity benefit paid in Scotland to people not well enough to work is one measure of the extent of our ill health. The life expectancy at birth of both men and women in Scotland in 1994 was lower than that in many other industrial countries (Figures 3 and 4).

Figure 3

Figure 4

11. Scottish mortality rates from CHD and cancer also compare unfavourably with this group of countries. Taking the genders separately:

• Scotland has the highest mortality rate from CHD for men and the second highest for women.
• women in Scotland have the highest mortality rates from cancer, while men in Scotland have the second highest rate.

The recent Scottish Health Survey compared the self-reported prevalence rates of CHD in Scotland and in England (Figure 5). The proportions of Scottish men and women with a history of CHD are much higher than in England. Almost 1 in 6 men aged 55-64 in Scotland have a history of CHD compared with just over 1 in 10 in England. The prevalence of CHD among women aged 55-64 in Scotland is almost double the rate for women in this age group in England.

Figure 5

Mental Health

12. Mental health, alongside cardiovascular disease (coronary heart disease and stroke) and cancer, is a top priority for the NHS in Scotland. Although there is no evidence to suggest that mental illness occurs more frequently in Scotland than in other industrialised countries, it is one of the most common forms of ill-health. In any year, about one-quarter of the population will experience some mental distress. Most of these will see their general practitioner at some point, but only a half will receive treatment explicitly for mental health problems. Ninety per cent of those treated suffer from depression or anxiety. Only 1 in 10 people with a mental health problem will be referred to the specialist mental illness services. Therefore, the general practitioner and his primary care team are the main providers of care. At least 1 in 10 of the 16 million consultations with GPs each year involves a mental health problem.

13. There is no evidence available about longer term trends in the incidence of mental illness in the population. The number of first admissions to mental illness hospitals and psychiatric units has remained relatively stable at around 9-10,000 patients a year, though these statistics should be treated with some caution since they do not necessarily reflect trends in the underlying incidence of mental health problems. The suicide rate among men and women aged 15-29 almost doubled during the 1980s, but has fallen since 1993. Although suicide rates in Scotland have been higher than in England, they are lower than in other Northern European countries.

14. Women who experience domestic violence are more likely to have poor health, depression, addictions, difficulties in pregnancy and to attempt suicide; and it has serious effects on children.

15. Children who are living in poverty, or experiencing parental separation or divorce, are at high risk of ill-health. So too are adults who are undergoing divorce or separation, who are unemployed or who are carers of highly dependent people.

16. Prescribing rates for patients with mental illness have risen sharply in recent years (Figure 6). The number of prescriptions for antidepressants increased from 1,429,000 in 1994-95 to 1,848,000 in 1996-97, a rise of almost 30% in the space of 2 years. Over the same period, the number of prescriptions issued for antipsychotic drugs rose by 12%. Again, these trends in prescribing do not necessarily reflect changes in the underlying incidence of mental illness in the community, but they illustrate the significant and growing pressures that treatment for mental illness imposes on the Health Service. It is known that not everyone with a mental health problem can access the treatment they need, often because of the effect it has on their capacity to seek help. As people’s needs are uncovered, so the pressures on services will increase.

Figure 6

17. As with health more generally, (see paragraph 32) mental illness is only one side of the coin. Mental well-being is vitally important in enabling us to fulfil positive, productive and rewarding roles in society and enhancing quality of life.

Dental and Oral Health

18. Scotland’s poor record of dental health led to dental and oral health being established as a health priority in 1991. One of the main targets set for the year 2000 was that 60% of 5 year old school entrants should have no cavities, fillings or extractions. In the late 1980s the figure was 42.3%, and there has been no significant change since then. It seems very unlikely, therefore, that the target of 60% by the year 2000 will be achieved.

19. The second target set in 1991 was that, by the year 2000, less than 10% of 45-54 year olds should be without their own teeth. There has been a significant improvement in this area: the proportion of this age group without their own teeth has fallen from 33% in 1988 to 17% in 1995. However, recent data suggest that the reduction may have levelled out and there is some doubt as to whether the target will be achieved.

20. Dental decay, the main cause of which is excessive use of refined sugar in food and drinks, is most pronounced among disadvantaged groups. The United Kingdom diet is high in sugar with an average consumption of over 140 grams per day (28 teaspoons). Reviews suggest that the Scottish diet has an even higher sugar content. Over 60% of 3 year-olds in disadvantaged areas of Scotland have dental decay.

21. An increasing incidence in oral cancer in recent times, especially in younger age groups, reminds us of the need to address aspects of oral health other than dental.

Obesity

22. There is growing concern about the rising prevalence of overweight and obese people in Scotland. This is not a problem unique to Scotland but one which is seen throughout the developed world. Obesity is now regarded as a medical condition in its own right as well as a marker of increased risk for a number of key health problems including CHD.

23. Certain people are more at risk of developing obesity than others. In families where one or both parents are overweight, the children are also more likely to be overweight. Risk of overweight and obesity is also associated with social class.

24. More than half of men and almost half of women in the recent Scottish Health Survey were above the recommended weight: 40% of men and 30% of women were classified as overweight while 16% of men and 17% of women were obese. And nearly 26% of men and 27.1% of women in social classes I and II were either overweight or obese compared with 33% of men and 43% of women in social classes IV and V. The prevalence of obesity was slightly higher in Scotland than in England.

Communicable Diseases

25. Substantial progress has been made in reducing the incidence of many forms of infectious disease. Much of this improvement is due to the success of the immunisation programmes established, for example for measles, mumps, rubella and whooping cough.

26. The annual number of food poisoning notifications in Scotland has doubled over the last 10 years. There has been an especially sharp rise in the number of reported cases of E coli 0157, and a serious outbreak towards the end of 1996 resulted in the death of 20 people.

27. HIV infection and AIDS have not resulted in the escalating epidemic anticipated in the mid-1980s. This is, in part, a tribute to the scope and effectiveness of public health measures, including health education, over the last decade. Nonetheless, there has been no evidence of any overall decrease in the number of new infections since 1988. A cumulative total of 2,725 people in Scotland were known to have become HIV infected by the end of 1997: of these, 1,011 are known to have died, many at a young age.

28. Statistics suggest that other sexually transmitted diseases are now on the increase among young men and increasing sharply among young women.

Accidents and Safety

29. In younger age groups, accidents are an important cause of death. In 1996 they accounted for 25% of deaths in boys, and 13% of deaths in girls, under 15 years of age. Almost half (43%) of deaths of young men aged between 15 and 34 years were attributed to accidents or suicide. Between 1983 and 1994 deaths from accidents in Scotland fell by 32%. This fall affected mainly the over 65 age group with little decrease in the death rate at younger ages. Over the same period, hospital admissions following accidents increased by 16%. Significant death rates were recorded from accidents in each of the main categories: work, leisure and sporting activities, road traffic and in the home. For example, in 1996-97, half a million working days were lost in Scotland as a result of accidents at work. The highest hospital admission rates were for work, leisure and sport-related accidents, followed by home and road traffic accidents. Increasingly, the focus is widening out from accidents to safety, with attention to aspects of quality of life in communities, including issues relating to crime against people and property.

Teenage Pregnancies

30. The rate of teenage pregnancies rose between 1986 and 1991 - from 44.4 to 50.5 per 1,000 women in the 13-19 age group. Although the rate fell to 43.1 in 1996, it remains a cause for concern. Among 16-19 year olds, the rate peaked in 1991 at 77.8 per 1,000 females in this age group and declined to 69.6 by 1996. Among 13-15 year olds, the rate increased from 7.5 per 1,000 females in 1986 to 9.6 in 1996.

31. Scotland does not have a specific current national target for reducing teenage pregnancies. The general policy has been that targets are best set locally in the light of local circumstances. Local targets have, therefore, been set at Health Board level. Twelve of the 15 Health Boards have set local targets to reduce the number of pregnancies amongst teenagers. Typically they are expressed in terms of a percentage reduction in conception rates for teenagers or a reduction in the number of teenage abortions.

Well-being and Fitness

32. Health is not just concerned with death and disease. Good health can, and must, be promoted by increasing physical, mental and social well-being and fitness while tackling and preventing health problems. This positive approach to health must be an essential component of a health improvement strategy, and will equip us better for every stage of life.

Inequalities in Health

33. In 1980, the Black Report drew attention to the contribution of socio-economic inequalities (as indicated by social class) to inequalities in health experience within the UK. More affluent people of both sexes and at all ages experienced less illness and premature death than the disadvantaged groups. A class gradient was observed for most causes of death, including stillbirth, accidents, cancers, respiratory disease and cardiovascular disease. Available data indicated a similar pattern with regard to chronic illness. Possible explanations for the relationship between health and inequality were considered, based on artefact, natural and social selection, culture or behaviour and economic and socio-structural factors. The report stated that there was no single or simple explanation, but stressed the importance of material conditions of life.

34. Further studies have confirmed the findings of the Black Report. These show not only that disadvantaged groups, whether in urban or rural environments or determined by ethnicity or gender, experience more chronic incapacitating illness at an earlier age, but also that socio-economic determinants of adult health, with particular regard to CHD, may date from very early life, including before birth.

35. Over the last twenty years or so, the gap in death rates between the most and least affluent categories has widened and a King’s Fund publication in 1995 states that, in Britain, death rates were 2-3 times higher among disadvantaged social groups than among the more affluent, and the disadvantaged were likely to die about 8 years earlier.

36. Illness shows a similar link to deprivation. It has been calculated that, in Lothian during 1995, 460 premature deaths would have been avoided if the entire population had shared the mortality experience of the most affluent. Similarly, more than £8m would have been saved if the overall rate of emergency hospital admissions had been as low as that of the most affluent. The differences between affluent and disadvantaged groups in Lothian in terms of premature deaths rates, rates of emergency hospital admissions and numbers of mental health outpatient referrals are all increasing over time.

37. The major inequalities in the health of different socio-economic groups within the Scottish population begin even before birth. Figure 7 shows the perinatal mortality rate among different social classes in 1995. The perinatal mortality rate in social class V is 11.1 per 1000 compared with 7.1 in social class I.

Figure 7

38. Children in the more deprived socio-economic groups are also more likely to be born prematurely and to have low birthweight. These factors are associated with greater likelihood of illness during childhood and adult life.

39. A number of studies has found that mortality rates are significantly higher among more deprived socio-economic groups. Figure 8 shows standardised mortality rates by the deprivation category of the area of residence. The all ages mortality rate shows a marked relationship with deprivation: in the most deprived areas, mortality rates are some 60% higher than in the most affluent areas. The relationship between deprivation and mortality is even stronger among people under 65. Mortality in this age group provides a crude proxy for general health. In 1991 the mortality rate among people under 65 in the most deprived areas was more than double the rate in the most affluent areas.

Figure 8

40. Similar results are found when death rates from specific diseases are compared by deprivation category (Figure 9). Mortality rates from CHD and cancer among people under 65 are much higher in areas of deprivation than in relatively affluent areas. And certain ethnic groups have a higher than average incidence of CHD and hypertension.

Figure 9

41. The gap in health between people living in the most affluent and the most deprived areas has widened during the 1980s (Figure 10).

Figure 10

In 1981, the standardised mortality rate in the most deprived areas was 120% above the rate in the most affluent areas. By 1991, this difference had increased to 162%.

42. Recent figures show that, in Scotland, teenage pregnancy rates are closely related to social deprivation categories, with the pregnancy rate for 13-19 year olds ranging from 17.2 per 1,000 girls in the least deprived categories to 68.6 per 1,000 in the most deprived. Young women living in the most deprived areas are considerably more likely to choose to continue their pregnancies than those living in the least deprived (47.0 per 1,000 to 4.9 per 1,000 at age 13-19). A study of 3,000 women showed a wide range of rates of post-natal depression, from 8% in social class I to 33% in social class V.

43. Figures 11-15 summarise the progress that has been made in key health areas since the mid-1980s.

Figure 11: significant reductions have occurred in mortality rates among people under 65 from coronary heart disease and, to a lesser extent, from cancer. There has also been a slight reduction in this age group in the mortality rate from stroke.

Figure 12: modest reductions have occurred in the percentage of people who smoke in the age ranges 12-24 and 25-64, though the targets set for the year 2000 are unlikely to be achieved.

Figure 13: the changes in alcohol consumption are disappointing with the percentages of both men and women drinking in excess of the weekly recommended limits increasing significantly since the mid-1980s.

Figure 14: the teenage pregnancy rate (per 1,000 females) increased from 7.5 in 1986 to 9.6 in 1996 among girls aged 13-15.

Figure 15: while there has been a significant reduction in the proportion of 45-54 year olds without their own teeth, there has been little change in the percentage of 5 year olds without cavities, fillings or extractions and it is very unlikely that the target set for the year 2000 will be achieved.

Progress in Priority Health Areas

Figure 11

Figure 12

Figure 13

Figure 14

Figure 15

Priority Health Topics

44. Scotland carries a greater burden of ill-health than other developed countries, with the problem being greatest among low income groups. The quest to lighten that burden starts with agreement on which conditions and illnesses to tackle most urgently, including action on the underlying inequalities.

45. Priorities should satisfy a number of criteria. They should:

• be major causes of premature death or avoidable ill-health;
• offer significant scope for reducing overall health inequalities;
• be open to effective prevention and/or positive health promotion; and
• be amenable to measurement and monitoring.

46. Using these criteria, the following priority health topics are proposed:

• CHD and stroke
• Cancer
• Mental health
• Sexual health, including teenage pregnancies and HIV/AIDS
• Dental and oral health
• Accidents and safety

  An overarching priority in each of these areas is to reduce inequalities.

The Government invite views on the suggested criteria and priority health topics.

47. Priority life circumstances and lifestyle factors are proposed in paragraph 81 and targets for priority health outcomes and lifestyle factors are discussed in paragraphs 198-212.